1. Echocardiography & Endocarditis
Echo Imaging Conference
1/20/10
Ethan Ellis, MD

2. Overview Background Diagnosis ACC/AHA indications for Echo
TTE versus TEE
Diagnostic Echo criteria
Echocardiographic estimation of outcome
Intracardiac complications of endocarditis
Surgical indications by Echocardiography

3. Background Infection of endocardium
valve leaflets, congenital defects, chamber walls or chordae, prosthetic valves/conduits

4. Background Infection of endocardium Diagnosis: modified Duke criteria
valve leaflets, congenital defects, chamber walls or chordae, prosthetic valves/conduits
Diagnosis: modified Duke criteria

6. 4 structural echo findings in Modified Duke Major criteria

7. Background Infection of endocardium Diagnosis: modified Duke criteria
valve leaflets, congenital defects, chamber walls or chordae, prosthetic valves/conduits
Diagnosis: modified Duke criteria
No noninvasive technique can definitively diagnose
Echocardiography has high sensitivity for IE and intracardiac abscess
Mandatory in the diagnosis and treatment of IE
ACC/AHA 2006 guidelines on valvular heart disease include recommendations for Echo use in native and prosthetic valve IE

8. Goals of Echo in Possible IE
Identify, localize, and characterize masses consistent with vegetations
Identify new valvular regurgitation
Examine prosthetic valve stability
Apply criteria to judge prognosis once vegetation identified

9. Accuracy of TTE Meta analysis 1984: 641 pts*
Mean sensitivity of 79% for detecting veg’s
More recently, decreased sensitivity despite tech improvements
7 studies, , Mean sensitivity of 62% 4-11
? d/t more rigorous case selection or d/t decreased TTE scrutiny now with TEE
Limitations
Underestimates size and complexity of large veg’s
May fail to detect small veg’s (< 3 mm)
*O'Brien, JT, Geiser, EA. Infective endocarditis and echocardiography. Am Heart J 1984; 108:386

10. Accuracy of TEE More invasive and expensive than TTE
High sensitivity in detecting and defining valve vegetations
Same 7 studies from , sensitivity 92% (compared to 62%)4-11
5 studies w/ similar results for sensitivity also revealed high specificity for TEE and TTE (93% vs 46% sensitivity, 96% vs 95% specificity) 4,8,10-12
ACC/AHA guidelines, main role of TEE is:
Nondiagnostic TTE
Prosthetic valve endocarditis
Assessment of complications

12. Diagnostic Echo criteria
Characteristics of mass likely to be a vegetation:
Texture: gray scale and reflectance of myocardium

15. Diagnostic Echo criteria
Characteristics of mass likely to be a vegetation:
Texture: gray scale and reflectance of myocardium
Location: upstream side of valve in path of jet or on prosthetic material

17. Diagnostic Echo criteria
Characteristics of mass likely to be a vegetation:
Texture: gray scale and reflectance of myocardium
Location: upstream side of valve in path of jet or on prosthetic material
Motion: choatic and orbiting, independent of valve motion
Prolapse into upstream chamber (i.e. MV mass into LA in systole)

19. Diagnostic Echo criteria
Characteristics of mass likely to be a vegetation:
Texture: gray scale and reflectance of myocardium
Location: upstream side of valve in path of jet or on prosthetic material
Motion: choatic and orbiting, independent of valve motion
Prolapse into upstream chamber (i.e. MV mass into LA in systole)
Shape: lobulated, amorphous
Accompanying abnormalities:
abscess, pseudoaneurysm, fistula, prosthetic dehiscence, paravalvular leak, new regurgitant lesion

20. Diagnostic Echo criteria
Characteristics of mass unlikely to be vegetation:
Texture: reflectance of calcium or pericardium (white)
Location: outflow tract attachment, downstream surface of valve
Shape: stringy or hair-like strands with narrow attachment
Lack of accompanying turbulent flow or regurgitation

21. False Positives Most common on TEE Lambl’s excrescences
Strands on sewing rings of prosthetics
Free suture
Redundant chordae, false tendons in LV
Chiari’s remnant in RA
Chordal insertion into normal MV
All of above tend to be highly reflective with echodensity similar to pericardium or aortic root. Dense, fibrotic, non-vibratory nature

24. False Negatives TTE>TEE Cannot definitively rule out endocarditis
High sensitivity of TEE (92-94%)
Cannot definitively rule out endocarditis
Low likelihood of IE if negative TEE in intermediate probability patient
In patients at high risk for IE (prosthetic valve, unexplained bacteremia), repeat examination reasonable

25. Echo Estimation of Outcome
TTE:
1991 Retrospective study. 204 pts with clinical criteria for IE.*
Clinical complications (drug failure, new CHF, embolization, surgery, death) compared to vegetation characteristics
Overall complication incidence 55%
Rates similar between native and prosthetic valves as well as between MV, TV, and AV
Size of vegetation most powerful predictor of complication
10% if 6 mm vegetation, 50% if 11mm vegetation, almost 100% if > 16 mm
Complications more frequent with higher grades of mobility and lesion extent
Vegetation consistency did not predict complications (except for calcified lesions which had no associated complications)
*Sanfilippo, AJ, Picard, MH, Newell, JB, et al. Echocardiographic assessment of patients with infectious endocarditis: Prediction of risk
for complications. J Am Coll Cardiol 1991; 18:1191.

30. Echo Estimation of Outcome
TEE:
Observations on TTE not directly applicable to TEE since given vegetation likely to appear larger on TEE
105 pts with IE, 1989*:
vegetation > 10 mm = increased incidence of embolization (47% v 19%, p<0.01)
Association particularly strong for MV endocarditis
Vegetation size and location did not predict other rates of complications (CHF, death)
178 pts with IE, 2002+:
Vegetation mobility confers additional risk beyond vegetation size
Embolic incidence higher with vegetation > 15 mm (70% vs 27%) and when vegetation moderately or severely mobile (62% vs 20% compared to low mobility)
Embolic rate 83% with large and severely mobile vegetations
Observational studies suggest risk of embolism declines after institution of antibiotic therapy
Echo predictors still apply after initiation of antibiotics
Greater vegetation size and mobility still predicted late embolic events
Increase in vegetation size after antibiotic start also predicted prolonged healing phase and a higher embolic risk
*Mugge, A, Daniel, WG, Frank, G, Lichtlen, PR. Echocardiography in infective endocarditis: reassessment of prognostic implications of
vegetation size determined by the transthoracic and the transesophageal approach. J Am Coll Cardiol 1989; 14:631.
+Di Salvo, G, Habib, G, Pergola, V, et al. Echocardiography predicts embolic events in infective endocarditis. J Am Coll Cardiol 2001; 37:1069.

32. Intracardiac Complications
Valvular regurgitation
Secondary infection of other valves
Leaflet perforation

36. Intracardiac Complications
Valvular regurgitation
Secondary infection of other valves
Leaflet perforation
Perivalvular abscess or fistula
Early invasion  cellulitis (echodense thickening of perivalvular tissue)  Necrosis and inflammation  abscess cavity
Abscess most likely with staph aureus
Risk of fistula formation
Abscess formation  increase in morbidity and mortality
TEE >TTE: 118 pts with IE, 1991, 44 with abscess at surgery/autopsy. 87% vs 28% sensitivity*
TEE still imperfect. Additional series 2007 showed TEE detecting only 48% of abscesses (21 of 44 pts)+
*Daniel, WG, Mugge, A, Martin, RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal
echocardiography. N Engl J Med 1991; 324:795.
+Hill, EE, Herijgers, P, Claus, P, et al. Abscess in infective endocarditis: the value of transesophageal echocardiography and outcome:
a 5-year study. Am Heart J 2007; 154:923.

39. Right Sided Endocarditis
Tricuspid valve vegetations most common in IV drug users
Most caused by staph aureus
Infrequently, R sided endocarditis due to involvement of PV
Often diagnosed only by TEE
most literature limited to single case reports
Most reports of R sided endocarditis have used TTE
In 48 IVDU pts with suspected IE, 22 with vegetations+
TTE and TEE equally sensitive and specific
TEE found no vegetations which were overlooked by TTE although vegetation usually better characterized by TEE
+San Roman, JA, Vilacosta, I, Zamorano, JL, et al. Transesophageal echocardiography in right-sided endocarditis. J Am Coll Cardiol
1993; 21:1226.

40. Prosthetic Valve Endocarditis
Findings suggestive of IE in prosthetic valves:
Vegetation
perivalvular abscess and fistula formation
impaired leaflet motion
valve rocking suggesting valve dehiscence
Perivalvular regurgitation.
* Must compare to prior. If no, moderate-severe suggestive of IE (not mild)
Echo evaluation can be limited by highly reflective prosthetic materials which block the passage of ultrasound
TEE has higher sensitivity than TTE (82-86% vs 36-43%)13-16
NPV close to 100% for TEE in native valve endocarditis but not for prosthetic valves making clinical assessment especially important
According to most recent ACC/AHA guidelines, TEE should be first line diagnostic test for possible IE in prosthetic valves

43. Surgery in IE

44. Summary
Echocardiogram part of major criteria in Modified Duke Criteria
Goals to aid in diagnosis, localize vegetations, assess for complications of IE
Mass texture, location, motion, shape, and associated abnormalities important
Vegetation size and mobility correlated with embolic complications in multiple studies
TEE more sensitive than TTE. Both highly specific.
NPV high for TEE. Role for repeat imaging in high risk patients
TEE better at detecting IE complications such as abscess, fistula, and leaflet perforation
TTE = TEE in detecting R sided endocarditis with exception of PV involvement
TEE > TTE for prosthetic valve IE and should be pursued directly
ACC/AHA guidelines from 2006 include recommendations for use of TTE/TEE
Generally TTE is preferred
Class I indications TEE: nondiagnostic TTEs, better assessment of abscess/complications, prosthetic IE
Class IIA indications TEE: persistent staph bacteremia without clear source
ACC/AHA for surgical intervention (severe valve dysfunction, abscess, other penetrating lesion)

45. References
1. Bonow, RO, Carabello, BA, Chatterjee, K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol 2006; 48:e1. 2. Bonow, RO, Carabello, BA, Chatterjee, K, et al Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e Role of Echocardiography in Infective Endocarditis. UpToDate Shively, BK, Gurule, FT, Roldan, CA, et al. Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis. J Am Coll Cardiol 1991; 18: Mugge, A, Daniel, WG, Frank, G, Lichtlen, PR. Echocardiography in infective endocarditis: reassessment of prognostic implications of vegetation size determined by the transthoracic and the transesophageal approach. J Am Coll Cardiol 1989; 14: Jaffe, WM, Morgan, DE, Pearlman, AS, Otto, CM. Infective endocarditis, : echocardiographic findings and factors influencing morbidity and mortality. J Am Coll Cardiol 1990; 15: Burger, AJ, Peart, B, Jabi, H, Touchon, RC. The role of two-dimensional echocardiology in the diagnosis of infective endocarditis [corrected] [published erratum appears in Angiology 1991 Sep;42(9):765]. Angiology 1991; 42: Pedersen, WR, Walker, M, Olson, JD, et al. Value of transesophageal echocardiography as an adjunct to transthoracic echocardiography in evaluation of native and prosthetic valve endocarditis. Chest 1991; 100: Daniel, WG, Mugge, A, Martin, RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med 1991; 324: Sochowski, RA, Chan, KL. Implication of negative results on a monoplane transesophageal echocardiographic study in patients with suspected infective endocarditis. J Am Coll Cardiol 1993; 21: Shapiro, SM, Young, E, De Guzman, S, et al. Transesophageal echocardiography in diagnosis of infective endocarditis. Chest 1994; 105: Birmingham, GD, Rahko, PS, Ballantyne, FD. Improved detection of infective endocarditis with transesophageal echocardiography. Am Heart J 1992; 123: Zabalgoitia, M, Garcia, M. Pitfalls in the echo-Doppler diagnosis of prosthetic valve disorders. Echocardiography 1993; 10: Daniel, WG, Mugge, A, Grote, J, et al. Comparison of transthoracic and transesophageal echocardiography for detection of abnormalities of prosthetic and bioprosthetic valves in the mitral and aortic positions. Am J Cardiol 1993; 71: Alton, ME, Pasierski, TJ, Orsinelli, DA, et al. Comparison of transthoracic and transesophageal echocardiography in evaluation of 47 Starr-Edwards prosthetic valves. J Am Coll Cardiol 1992; 20: Roe, MT, Abramson, MA, Li, J, et al. Clinical information determines the impact of transesophageal echocardiography on the diagnosis of infective endocarditis by the Duke criteria. Am Heart J 2000; 139:945.